HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 24 PATTON LANE 5/14/2020 RECEIVED
�L\ Commonwealth of Massachusetts mAY 14 2.020
W City/Town of North Andover
SSystem Pumping Record TOWN UF NOR(HANDUVER
Y p g HEALTH DEPARTMENT
Form 4
'GSM
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 24 Patton Lane
key to move your Address
cursor-do not North Andover MA 01845-4925
use the return key. City/Town State Zip Code
m
2. System Owner:
Richard Oconnell _
Name
nem
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping pate 4/30/2020 1500
2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): — -- — -
4. Effluent Tee Filter present? Yes ® No If yes, was it cleaned? Yes ® No
5. Condition of System:
Good, system operating properly
6. System Pumped By:
Jason Elliott S71437
Name Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
7. Location where contents were disposed:
GLSD
_ 4/30/2020
Sig ure of Hauler Date
Signature of Receiving Facility Date
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